Canaries in a Coal Mine

[medgator]

I wouldn't feel too comfortable if I was in an independent radonc group in the current market and encouraging the expansion of the radonc labor pool. The hospitals are finding it pretty cheap to hire radoncs instead of working with radonc groups and are therefore bypassing radonc groups and hiring radoncs as employees. I'm an example of a relatively new employee who the hospital found it cheaper to hire as an employee than to work with another local radiation group.

It has nothing to do with how cheap or expensive it is to hire you and everything to do with controlling the rad onc in-house, rather than letting an independent group work in the system. That way, you'll send to other employed hospital docs and vice versa. Plus if that group had their own linac, the hospital would have the risk of having the technical revenue diverted away. If given the choice, hospital would prefer to employ a rad onc, especially if they own the machine and have an associated medical group.

I work in an environment with both employed and independent physicians and have seen this happen before. Independents support independents and employed docs keep referrals within the employed group.

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[mpdoc2]

It has nothing to do with how cheap or expensive it is to hire you and everything to do with controlling the rad onc in-house, rather than letting an independent group work in the system. That way, you'll send to other employed hospital docs and vice versa. Plus if that group had their own linac, the hospital would have the risk of having the technical revenue diverted away. If given the choice, hospital would prefer to employ a rad onc, especially if they own the machine and have an associated medical group.

I work in an environment with both employed and independent physicians and have seen this happen before. Independents support independents and employed docs keep referrals within the employed group.

My point is that if the labor pool was tighter the hospitals would have less leverage on hiring and would be more willing to work with radonc groups (even if it means the groups will get only the professional fees). Hospital takeovers are happening everywhere and thats partially because the recruiters have noticed this glut in the radonc pool and have informed their hospitals (a local recruiter told me this).

 

[OTN]

My point is that if the labor pool was tighter the hospitals would have less leverage on hiring and would be more willing to work with radonc groups (even if it means the groups will get only the professional fees). Hospital takeovers are happening everywhere and thats partially because the recruiters have noticed this glut in the radonc pool and have informed their hospitals (a local recruiter told me this).

I'm skeptical of this. The capital needed to embark on a radiation oncology program is substantial, with the radonc salary (assuming an employed position) a small part of the overall cost of operation. While it would bolster the bottom line a bit to be able to get a radonc more cheaply than before, I'd be surprised if it were enough to push a hospital to move to takeover a group. Sure, the recruiter may have told the hospital this and assumed it made a big impact on their decision whether or not to pursue, but the recruiter doesn't have a full picture of what's needed to run a quality radonc program.

 

[mpdoc2]

I'm skeptical of this. The capital needed to embark on a radiation oncology program is substantial, with the radonc salary (assuming an employed position) a small part of the overall cost of operation. While it would bolster the bottom line a bit to be able to get a radonc more cheaply than before, I'd be surprised if it were enough to push a hospital to move to takeover a group. Sure, the recruiter may have told the hospital this and assumed it made a big impact on their decision whether or not to pursue, but the recruiter doesn't have a full picture of what's needed to run a quality radonc program.

Up until very recently it would cost hospitals >500K/ year to employ a radonc. That's actually a fairly major expense of a single linac radonc center. I know their numbers and their breakdowns.

 

[OTN]

Up until very recently it would cost hospitals >500K/ year to employ a radonc. That's actually a fairly major expense of a single linac radonc center. I know their numbers and their breakdowns.

And what would it cost now? What's the delta?

 

[mpdoc2]

And what would it cost now? What's the delta?

300K, you can buy a used linac for <1mill

 

[medgator]

300K, you can buy a used linac for <1mill

Cheapest I've seen was $350k for a used iX, but then you have to account for install and room costs, could easily add a few hundred K

 

[mpdoc2]

Cheapest I've seen was $350k for a used iX, but then you have to account for install and room costs, could easily add a few hundred K

Exactly, my point is an expensive radonc is not an insignificant cost for a radonc center.

 

[OTN]

Exactly, my point is an expensive radonc is not an insignificant cost for a radonc center.

No, I meant what are employed positions paying now? They're not paying $0, so hospitals wouldn't save $500k/yr. If they're saving $300k/yr compared with before that might make a difference, but if they're saving $100k/yr I'm not sure that would be enough.

 

[Neuronix]

No, I meant what are employed positions paying now? They're not paying $0, so hospitals wouldn't save $500k/yr. If they're saving $300k/yr compared with before that might make a difference, but if they're saving $100k/yr I'm not sure that would be enough.

The MBA at the top sees it this way:

The rad onc was getting paid $500k/year.
Now there's a surplus of graduates who are willing to be paid $300k/year (or sometimes even less).

That's a difference of $200k/year. That money can go straight into other projects within the hospital system or even into his or her pocket.

Plus, if it was outside group that they were contracting previously, the employed rad onc will be forced to refer internally. That makes the hospital even more money.

Further, you should see the crazy non-competes that some of these centers are forcing on people now. If you ever quit, you will have to sell your house and probably never look back.


This is a win-win for the hospital systems. It's a losing proposition for physicians except for the untouchables at the tops of non-profit or academic medical systems who make these decisions and reap the rewards.

 

[mpdoc2]

The MBA at the top sees it this way:

The rad onc was getting paid $500k/year.
Now there's a surplus of graduates who are willing to be paid $300k/year (or sometimes even less).

That's a difference of $200k/year. That money can go straight into other projects within the hospital system or even into his or her pocket.

Plus, if it was outside group that they were contracting previously, the employed rad onc will be forced to refer internally. That makes the hospital even more money.

Further, you should see the crazy non-competes that some of these centers are forcing on people now. If you ever quit, you will have to sell your house and probably never look back.


This is a win-win for the hospital systems. It's a losing proposition for physicians except for the untouchables at the tops of non-profit or academic medical systems who make these decisions and reap the rewards.

Exactly, unfortunately the partners in private practices are also screwing the new graduates and making the potential screw by the hospital better than the private practice (who as per a previous post are trying to hire them as fellows or non-partner track employees).

 

[OTN]

The MBA at the top sees it this way:

The rad onc was getting paid $500k/year.
Now there's a surplus of graduates who are willing to be paid $300k/year (or sometimes even less).

That's a difference of $200k/year. That money can go straight into other projects within the hospital system or even into his or her pocket.

Plus, if it was outside group that they were contracting previously, the employed rad onc will be forced to refer internally. That makes the hospital even more money.

Further, you should see the crazy non-competes that some of these centers are forcing on people now. If you ever quit, you will have to sell your house and probably never look back.


This is a win-win for the hospital systems. It's a losing proposition for physicians except for the untouchables at the tops of non-profit or academic medical systems who make these decisions and reap the rewards.

Sure, I get that it makes starting a radiation program $200k/year more attractive, but my point is that the amount of capital/employees you need to start most radonc programs is more substantial than you would other outpatient services. As a result, a drop in physician salary won't be as impactful as it otherwise might be in another specialty.

I think in radonc it's not unreasonable to have a non-compete in a contract. Our large private practice group has one, which I was fine with signing. However, our group is also large enough that we will never, ever take advantage of the glut of radoncs from a hiring perspective. The new grads now get the same deal, partnership-wise, that we've always given everyone.

 

[Gfunk6]

A few benefits of living in California:

1. With narrow exceptions it is illegal for corporations to employ physicians. Therefore, most Rad Oncs have a professional:technical split with the hospital.
2. Restricted covenant (non-complete clauses) are illegal and unenforceable.
3. CA is not a CoN (certificate of need) state so if you want to put up 10 linacs in the same town, it can be done

Also, the scenarios being cited above imply that a hypothetical Rad Onc is working alone or perhaps in a single specialty group. They have little/no bargaining power/leverage and can be replaced. Consider if that same Rad Onc is part of a multi-specialty group with Med Oncs & Surgeons - quite a different proposition to displace that person from the hospital.

 

[mpdoc2]

A few benefits of living in California:

1. With narrow exceptions it is illegal for corporations to employ physicians. Therefore, most Rad Oncs have a professional:technical split with the hospital.
2. Restricted covenant (non-complete clauses) are illegal and unenforceable.
3. CA is not a CoN (certificate of need) state so if you want to put up 10 linacs in the same town, it can be done

Also, the scenarios being cited above imply that a hypothetical Rad Onc is working alone or perhaps in a single specialty group. They have little/no bargaining power/leverage and can be replaced. Consider if that same Rad Onc is part of a multi-specialty group with Med Oncs & Surgeons - quite a different proposition to displace that person from the hospital.

Actually those aren't really advantages for groups in California.

In CA there's a workaround the "no hiring doctors" thing where hospitals create another LLC which employs the physicians. They are essentially the same group but with different names and Tax-IDs to get around that CA law.

The hospitals are also buying up the Medonc and Surgery groups to become self sufficient. The only thing hospitals really need are the primary care groups which they've had a tendency of buying up as well in California. The problem is the differential reimbursement for hospitals compared to private groups. Hospitals are getting double/triple the reimbursement for medoncs in my area compared to private practices.

 

[medgator]

A few benefits of living in California:

1. With narrow exceptions it is illegal for corporations to employ physicians. Therefore, most Rad Oncs have a professional:technical split with the hospital.
2. Restricted covenant (non-complete clauses) are illegal and unenforceable.
3. CA is not a CoN (certificate of need) state so if you want to put up 10 linacs in the same town, it can be done

The restrictive covenant can be a positive if you've developed a strong referral network and one of your associates wants to leave and set up their own shop in town. Hated signing one as an employee but now, as a partner, I am glad they exist as referral patterns can take years to develop and establish. Our med onc partners are restricted only from joining/starting radiation for 2 years after leaving, otherwise there are no geographic restrictions on them.

From what I hear about contracting/rates, California (especially SoCal) can be pretty cutthroat in terms of reimbursement secondary to the number of centers that are competing with each other

 

[Neuronix]

The restrictive covenant can be a positive if you've developed a strong referral network and one of your associates wants to leave and set up their own shop in town.

"In town" is one thing. I know one shop whose non compete is something like 2 years within a large chunk of a large state. You would have no choice but to uproot your family if you ever left that position. I hear about worse--like not being able to practice anywhere near a chain of practices within a state which effectively cuts off much of a state. What's reasonable here?

 

[medgator]

"In town" is one thing. I know one shop whose non compete is something like 2 years within a large chunk of a large state. You would have no choice but to uproot your family if you ever left that position. I hear about worse--like not being able to practice anywhere near a chain of practices within a state which effectively cuts off much of a state. What's reasonable here?

In FL, they can be enforced, but they have to be "reasonable" 2 years would likely be struck down, 6-12 months maybe not. It's still a hassle to litigate, and really the lawyers end up winning in the end, so I imagine a lot of these cases end up getting settled, or in some cases, the RC ends up not being enforced at all.

 

[OTN]

In FL, they can be enforced, but they have to be "reasonable" 2 years would likely be struck down, 6-12 months maybe not. It's still a hassle to litigate, and really the lawyers end up winning in the end, so I imagine a lot of these cases end up getting settled, or in some cases, the RC ends up not being enforced at all.

Very tough to enforce these non-compete clauses in Texas as well, which is a "right-to-work" state.

 

[ape2ag]

As I have posted on other threads, the only organization that can change the number of radiation oncology resident positions is SCAROP. This is where your ire should be directed and I would encourage you to attempt to persuade them. This is not a situation that ASTRO can fix (they want more members and have no jurisdiction), ACGME cannot fix either as it is specifically forbidden to discuss workforce issues as it relates to training programs or positions (restriction of trade and so forth). Do something constructive and gather a group of like-minded individuals and appeal to SCAROP.

SCAROP isn't that influential. The annual meetings are poorly attended (by maybe 1/3rd of the chairs) and the major programs don't send representation. Maybe there is some sort of coordinated cabal of the top program chairs that drives the specialty, but it's not through SCAROP. Most program chairs are out of the decision making loop.

 

[Neuronix]

In FL, they can be enforced, but they have to be "reasonable" 2 years would likely be struck down, 6-12 months maybe not. It's still a hassle to litigate, and really the lawyers end up winning in the end, so I imagine a lot of these cases end up getting settled, or in some cases, the RC ends up not being enforced at all.

Kicking up old thread because... Well I was gonna link to it.

The reality is that when you have an non-compete, it works as a deterrent for other places to hire you. It may or may not be enforceable, so nobody hiring wants to take that risk. With a job market glut, it's not like anyone in a competitive location is hurting for potential candidates. So even if they like you, they don't want to hire someone and have to defend them in court, or have them leave in some number of months if the non-compete is enforceable, or buy them out of their non-compete. They'll just move on to the next guy.

This is entirely to keep control of the physicians and essentially remove all negotiating power while tightening the screws on them. A lot of people feel trapped in their positions this way. It's a very gotcha, business type mentality. Non-competes should be outlawed as the legal profession did for themselves a long time ago.

 

[medgator]

One could argue that this is the problem with a professional/physician non-compete. This isn't like a secret sauce recipe that needs to be guarded. Its a way to control another physician's ability to practice based on their own skills. If a physician leaves a group and can get referrals because they are well liked, offer a unique skill/service, etc. that is not a reason to try to limit competition.

Yup. It all comes down to state law.. Some states totally see it as anti-competitive and preventing physicians from having livelihood once they are established in that geographic area, while others believe it is legally enforceable if someone signs it.

 

[Gfunk6]

I should point out that even in states where non-competes are unenforceable (e.g. CA) it is still possible to include it in job agreements. This would cost the physician about $75,000 in legal fees to extricate themselves. Yet another reason to always have a lawyer review employment contracts.

 

[medgator]

I should point out that even in states where non-competes are unenforceable (e.g. CA) it is still possible to include it in job agreements. This would cost the physician about $75,000 in legal fees to extricate themselves. Yet another reason to always have a lawyer review employment contracts.

Interesting... if it's not enforceable, what would that money go towards? I would just think you could walk away and be done with it.

And yes want to emphasize to everyone it's a good idea for an attorney in the state of your future practice (preferably a healthcare attorney) to review the contract

 

[texan2009]

Zeitmans prophesy came true. This should be cause for drastic changes in our field but I am afraid it will he solved with desperate and eager foreign grads.

 

[medgator]

Could have just bumped the existing thread

Canaries in a Coal Mine

I recently attended the Annual UCSF Rad Onc course. One of the featured speakers was Anthony Zietman. Dr. Zietman has always been a highly engaging speaker and his topic was particularly timely - "the future of RO as a specialty." Many, many interesting points came out of this talk: 1. He...

forums.studentdoctor.net

But yes, zietman was correct. Amazing what information symmetry can do to a field. Maybe Dr O should think about things long and hard rather than hating sdn for bringing this important issue to the forefront

Doesn't every Mayo satellite now have a residency? Could start with that problem right there

 

[Sheldor]

Wow, down 25% from the lowest year ever? That's pretty incredible.

 

[scarbrtj]

Apropos and germane to this, I don't think this drop is simply due to the workforce and oversupply trope now. It's a driver, sure, but current medical students are even savvier than this distractor and see even bigger issues. For example... Varian announced a new A.I. platform that ultimately is going to dramatically reduce the work of physician contouring. "If [a doctor is] sitting at a console marking outlines ... it's not the best use of [the doctor's] time" according to Varian. And Nancy Lee used to "brag" that H&N contouring for a single NPC case took her ~3 hours. (And rad onc residents, evidently, love contouring.) If the laboriousness of contouring is dramatically reduced... if it can actually be done by computer and the MD's role is simply to check it... well you know the rest of the story. It changes the field. It changes the field's needs. And maybe it does all go back to oversupply! But in summary, current young people I think are actually smart.

 

[RadOncMegatron]

Who could've predicted this... oh wait!

Seriously, he didn't mention anything about any other issues besides the ABR testing debacle. Head in the sand.

Can we trust the folks who created this mess to clean it up?

 

[fiji128]

The huge issues with this field is apparent to anyone willing and be honest with what they see. I know many recent rad oncs grads that have jobs but would love to move if they could find a better fitting position or a better location, except there really aren't any that they know about or have access to. In almost all other medical specialties finding a quality position is not THE over ridding issue like it is in ours except for maybe pathology. The field's leadership seems largely unconcerned or in denial. Maybe if the match this year is another debacle those at the top will start to actually take notice but I honestly think the response will be, hey we are the new pathology just get use to it.

Why would anyone sign up for that?

 

[xrthopeful]

****s getting real now!

 

[Neuronix]

Could have just bumped the existing thread

Agreed. I merged the threads.

 

[deleted774703]

Apropos and germane to this, I don't think this drop is simply due to the workforce and oversupply trope now. It's a driver, sure, but current medical students are even savvier than this distractor and see even bigger issues. For example... Varian announced a new A.I. platform that ultimately is going to dramatically reduce the work of physician contouring. "If [a doctor is] sitting at a console marking outlines ... it's not the best use of [the doctor's] time" according to Varian. And Nancy Lee used to "brag" than H&N contouring for a single NPC case took her ~3 hours. (And rad onc residents, evidently, love contouring.) If the laboriousness of contouring is dramatically reduced... if it can actually be done by computer and the MD's role is simply to check it... well you know the rest of the story. It changes the field. It changes the field's needs. And maybe it does all go back to oversupply! But in summary, current young people I think are actually smart.

Lol I think that resident is trying to be the 1st rad onc social media influencer

 

[OTN]

Do they really think focusing on the board exams/curriculum creation is going to move the needle at all when it comes to radonc applicants? Really? I think the academicians are underestimating both the intelligence and knowledge of current medical students and avoiding the hard work of actually reforming the field. Maybe I'm wrong and curriculum development will help get good medical students interested in the field again, but I doubt it.

The Mayo system has radiation oncology residency programs in Minnesota, Arizona, and Florida.

 

[RickyScott]

Do they really think focusing on the board exams/curriculum creation is going to move the needle at all when it comes to radonc applicants? Really? I think the academicians are underestimating both the intelligence and knowledge of current medical students and avoiding the hard work of actually reforming the field. Maybe I'm wrong and curriculum development will help get good medical students interested in the field again, but I doubt it.

The Mayo system has radiation oncology residency programs in Minnesota, Arizona, and Florida.

Given the expected quality of applicants coming down the pike, they will need all the help they can get....

 

[deleted956486]

Do they really think focusing on the board exams/curriculum creation is going to move the needle at all when it comes to radonc applicants? Really? I think the academicians are underestimating both the intelligence and knowledge of current medical students and avoiding the hard work of actually reforming the field. Maybe I'm wrong and curriculum development will help get good medical students interested in the field again, but I doubt it.

The Mayo system has radiation oncology residency programs in Minnesota, Arizona, and Florida.

Why reform the field when they have it so good?

 

[GapCalc]

Charting Outcomes in the Match 2020 is going to be a juicy read.

Man, what a cluster%#%$. I love that on the same day that this info was released, ASTRO is going through the annual awards ceremony. Congrats everyone! Great work!

 

[Mandelin Rain]

Anyone hearing about APM? I'm hearing anticipated % reduction of reimbursement in the high single digits for those participating. Worse if you've been doing the right thing all along.

Make that cheddar while you can young bloods. To the canaries currently entering this coal mine; bring a respirator.

 

[deleted956486]

Anyone hearing about APM? I'm hearing anticipated % reduction of reimbursement in the high single digits for those participating. Worse if you've been doing the right thing all along.

Make that cheddar while you can young bloods. To the canaries currently entering this coal mine; bring a respirator.

Single digits???? I've heard 30ish % reductions from 3 different sources on the professional side.

 

[WanderingRad3]

Single digits???? I've heard 30ish % reductions from 3 different sources on the professional side.

Per ASTRO, The cut is ~6% - but hopefully will be much less once the final rule comes out - which Astro is describing as an “alternative payment cut”

 

[Mandelin Rain]

Single digits???? I've heard 30ish % reductions from 3 different sources on the professional side.

The number I heard was global, and I assumed it was symmetric betwixt tech and pro. 30% would be catastrophic. It's hard to believe that would happen, Maybe for some diagnoses (brain SRS). But again, buyer beware.

 

[medgator]

Charting Outcomes in the Match 2020 is going to be a juicy read.

Man, what a cluster%#%$. I love that on the same day that this info was released, ASTRO is going through the annual awards ceremony. Congrats everyone! Great work!

Will look great at this too

 

[OTN]

6-8% cut is what it looks like right now, but that was CMS's opening salvo. I'm hoping we get some of that back in negotiations, which I think is reasonable to expect. Personally. I think that's why they put that 5% "discount" in there, so they could remove it during negotiations. Who knows.

30% cut would mean the vast majority of radonc departments would be non-viable.

 

[BobbyHeenan]

Do they really think focusing on the board exams/curriculum creation is going to move the needle at all when it comes to radonc applicants? Really? I think the academicians are underestimating both the intelligence and knowledge of current medical students and avoiding the hard work of actually reforming the field. Maybe I'm wrong and curriculum development will help get good medical students interested in the field again, but I doubt it.

The Mayo system has radiation oncology residency programs in Minnesota, Arizona, and Florida.

This was my take as well.

The boards fiasco was a small straw in a giant pile on the camel's back.

Med students are worried about being able to live in a geographic region, their salary, and their post residency employment options/salary >>>>>>> a physics/rad bio board exam.

They're deluding themselves if they think fixing the boards issue will "fix" lack of interest in the applicant pool.

 

[Mandelin Rain]

Interest in Rad Onc sky rocketed when salary in Rad Onc sky rocketed.

It is really that simple. It was an easy lifestyle to make a lot of money.

Yadda yadda all the noble reasons to be a rad onc (it really is a great field), the truth is C.R.E.A.M. Mess with the money (including the potential for $0 salary) and you'll mess with the interest.

The money has been messed with.

 

[medgator]

Interest in Rad Onc sky rocketed when salary in Rad Onc sky rocketed.

It is really that simple. It was an easy lifestyle to make a lot of money.

Yadda yadda all the noble reasons to be a rad onc (it really is a great field), the truth is C.R.E.A.M. Mess with the money (including the potential for $0 salary) and you'll mess with the interest.

The money has been messed with.

There's still money in Quincy, Illinois. Or Wyoming probably

 

[scarbrtj]

The Mayo system has radiation oncology residency programs in Minnesota, Arizona, and Florida.

I read this and immediately thought "The Mayo system has a radiation oncology residency program in Minnesota" would have been the correct statement not that long ago.

 

[medgator]

I read this and immediately thought "The Mayo system has a radiation oncology residency program in Minnesota" would have been the correct statement not that long ago.

Yup. Both the satellites created residencies since the turn of the century. Scottsdale in 2013.

Exhibit A of a major problem that people like Dr O are in power to solve

 

[BobbyHeenan]

I actually think physics and rad bio board certification remains important, largely because I think without that you very well may have seen neurosurgeons doing gamma knife without a rad onc.

With PSMA-targeted therapeutics and Lutathera and others coming around, then it at least is something to distinguish our skill set or knowledge base.

 

[OTN]

I actually think physics and rad bio board certification remains important, largely because I think without that you very well may have seen neurosurgeons doing gamma knife without a rad onc.

With PSMA-targeted therapeutics and Lutathera and others coming around, then it at least is something to distinguish our skill set or knowledge base.

Sure, I agree it's important, but to suggest that effing BOARDS are what are keeping med students from this specialty is laughable at best.

 

[RickyScott]

KO from my few interactions with him is actually a really good guy and very collegieal. These guys need to bed educated in the worst way.